Provider Demographics
NPI:1477899003
Name:SAM CORP
Entity Type:Organization
Organization Name:SAM CORP
Other - Org Name:ASDFASDFASDF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRSIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-334-3433
Mailing Address - Street 1:1400 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-5306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W 42ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7612
Practice Address - Country:US
Practice Address - Phone:305-343-4443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASFASDFASDFASDF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-01
Last Update Date:2013-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service